Decoding the persistence of delayed hospital discharge: An in‐depth scoping review and insights from two decades

Abstract Objective This article addresses the persistent challenge of Delayed Hospital Discharge (DHD) and aims to provide a comprehensive overview, synthesis, and actionable, sustainable plan based on the synthesis of the systematic review articles spanning the past 24 years. Our research aims to comprehensively examine DHD, identifying its primary causes and emphasizing the significance of effective communication and management in healthcare settings. Methods We conducted the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses extension for Scoping Reviews (PRISMA‐ScR) method for synthesizing findings from 23 review papers published over the last two decades, encompassing over 700 studies. In addition, we employed a practical and comprehensive framework to tackle DHD. Rooted in Linderman's model, our approach focused on continuous process improvement (CPI), which highlights senior management commitment, technical/administrative support, and social/transitional care. Our proposed CPI method comprised several stages: planning, implementation, data analysis, and adaptation, all contributing to continuous improvement in healthcare delivery. This method provided valuable insights and recommendations for addressing DHD challenges. Findings Our DHD analysis revealed crucial insights across multiple dimensions. Firstly, examining causes and interventions uncovered issues such as limited discharge destinations, signaling unsustainable solutions, and inefficient care coordination. The second aspect explored the patient and caregiver experience, emphasizing challenges linked to staff uncertainty and negative physical environments, with notable attention to the underexplored area of caregiver experience. The third theme explored organizational and individual factors, including cognitive impairment and socioeconomic influences. The findings emphasized the importance of incorporating patients' data, recognizing its complexity and current avoidance. Finally, the role of transitional and social care and financial strategies was scrutinized, emphasizing the need for multicomponent, context‐specific interventions to address DHD effectively. Conclusion This study addresses gaps in the literature, challenges prevailing solutions, and offers practical pathways for reducing DHD, contributing significantly to healthcare quality and patient outcomes. The synthesis introduces the vital CPI stage, enhancing Linderman's work and providing a pragmatic framework to eradicate delayed discharge. Future efforts will address practitioner consultations to enhance perspectives and further enrich the study. Patient or Public Contribution Our scoping review synthesizes and analyzes existing systematic review articles and emphasizes offering practical, actionable solutions. While our approach does not directly engage patients, it strategically focuses on extracting insights from the literature to create a CPI framework. This unique aspect is intentionally designed to yield tangible benefits for patients, service users, caregivers, and the public. Our actionable recommendations aim to improve hospital discharge processes for better healthcare outcomes and experiences. This detailed analysis goes beyond theoretical considerations and provides a practical guide to improve healthcare practices and policies.


| INTRODUCTION
As the global population ages, healthcare systems in developed countries face increasing pressures to meet demand and manage costs.The United States has witnessed a surge in healthcare demand due to aging and chronic diseases, leading to growing costs. 1 The rise in chronic diseases, at 4.2% annually, contributes significantly to increased demand. 2 As the aging population grows, healthcare costs rise, making cost management crucial for quality patient care. 3,4layed Hospital Discharge (DHD) is a critical issue that occurs when patients ready for discharge remain in hospitals due to a lack of external care facilities. 5,6This issue, known by various terms globally, prolongs hospital stays, increases costs, reduces capacity, and leads to poorer patient outcomes.9][10][11] The literature on healthcare management and patient outcomes offers insights into healthcare system challenges.Åhlin et al.   identified barriers to hospital patient flow, suggesting a need for further research. 12 Glasby et al. and Bhatia et al. highlighted DHD   issues in the United States and Canada, respectively, 13,14 calling for systemic solutions and policy changes.Micallef et al. explored DHD in acute settings, emphasizing the need for practical policy implications. 5Philp et al. reported on interventions to reduce hospital bed use among frail older people. 15Meanwhile, van Sluisveld et al. evaluated clinical handover quality at patient discharge, noting the need for better research methods. 16Modas et al. assessed tools for predicting prolonged hospital stays, with a gap noted in practical healthcare policy implications. 10Plante et al. linked cognitive impairment to longer hospital stays, suggesting the need for strategies to address the issue. 8Lin et al. focused on contributing factors to the ICU discharge, 9 and Rameli and Rajendran reviewed the effectiveness of multidisciplinary discharge planning teams. 17ltonen et al. looked at organizational factors in critical care settings, identifying a need for more generalizable evidence. 18adley et al. and Fox et al. examined discharge planning's effectiveness, with a call for understanding study limitations and providing clearer policy implications. 19,20McGilton et al. provided insights into transitional care programs (TCPs) for older adults with DHD, emphasizing the need for more research. 21 Spiers et al.   examined social care's impact on healthcare utilization, identifying a need for comprehensive evidence. 22Everall et al. and Rojas-García et al. analysed DHD experiences from patient and caregiver perspectives, highlighting the need for more holistic approaches and practical recommendations. 23,24Cadel et al. reviewed DHD initiatives, calling for more thorough patient experience reporting. 6ndeiro investigated DHD costs, advocating for standardized methods and patient-centred approaches. 3 Mason et al. considered   integrating health and social care funds, emphasizing the need for careful planning. 25 is evident that the DHD literature lacks consensus on its causes and outcomes.This study systematically reviews review articles from the past decade to understand perspectives and identify primary reasons and contributing factors.Scoping reviews focusing on published systematic reviews offer benefits, helping policymaking by providing an overview of existing research and identifying knowledge gaps.Published systematic reviews offer insights from multiple studies, providing a broader perspective on DHD factors.
Their methodological rigour ensures reliable evidence for policy recommendations, facilitating evidence-based decision-making and providing efficient guidance for healthcare systems to address DHD.

| MATERIALS AND METHODS
This study utilized the PRISMA-ScR method, a structured approach for conducting scoping reviews, ensuring transparency and rigour in methodology, 21,26 and enhancing the reliability and credibility of our study outcomes.Following the five stages outlined by Levac et al., 27 we identified the research question, relevant literature, selected studies for inclusion, organized data, and summarized results.Leveraging the Cochrane Review of Systematic Reviews, our scoping review provides evidence-based insights for healthcare decision-making, integrating findings from multiple studies. 28By presenting a comprehensive summary, we aim to bridge the research-to-practice gap and potentially enhance patient outcomes.Our scoping review aims to clarify the current state and identify ways to improve DHD solutions.

| Identifying research questions
Despite extensive research, DHD remains problematic, with worsening consequences for patients and healthcare systems.The scoping review was guided by two specific research questions: (1) What are the primary causes and contributing factors that aggravate the DHD problem? and (2) Which interventions and funding programs have alleviated the DHD issue?

| Identifying relevant studies
To investigate the impacts of DHD, we searched electronic databases for systematic (or scoping) reviews published in English from 2000 until 31 January 2024.This timeframe ensures relevance to current healthcare systems by focusing on literature post-2000, reflecting significant evolutions in healthcare management.Databases used for this search included Scopus, Web of Science, EMBASE (Ovid interface), CINAHL, and PubMed.The search strategy involved keywords related to hospital discharge delays, as follows: ('delayed discharge'), ('alternate level of care'), ('inappropriate use of bed'), ('inappropriate hospital use'), ('inappropriate acute bed use'), ('inappropriate bed use'), ('discharge delay'), ('bed block*'), ('social admission'), and ('delay* transfer').Englishlanguage and review articles were included after applying filters to streamline search results.Reference lists from identified articles were examined for further relevant studies.Google Scholar was used to capture grey literature, including resources like technical reports.
Covidence ® is a web-based tool for systematic reviews that helped us to minimize bias by organizing search results, facilitating full-text screening, and data extraction.Articles that passed the initial screening were further evaluated for their relevance and quality based on the set inclusion criteria.The final selection comprised 23 articles, from which one author systematically extracted and analysed data to address the research question.

| Study selection
Our inclusion/criteria encompassed systematic review articles on DHD from the past two decades.Exclusion criteria were nonsystematic reviews, non-English articles, and studies not centrally focused on DHD (Table 1).We did not restrict our search by patients' discharge destinations, as this would narrow the scope of factors explored for DHD.This broad criterion ensured an inclusive analysis of diverse factors impacting DHD.Detailed inclusion/exclusion criteria for the 23 selected articles are outlined in Table C2.

| Charting the data
Data extraction from Covidence ® to a Microsoft Excel Workbook was employed for charting purposes.The charted data encompassed details such as the primary author, publication year, article title, study objectives, and inclusion/exclusion criteria.These data are presented in Tables 2-5, and the comprehensive details can be found in Tables C1 and C2.
T A B L E 1 The inclusion and exclusion criteria for this study.

| COLLATING, SUMMARIZING, AND REPORTING THE RESULTS (PRISMA)
The initial search retrieved a total of 806 articles from databases, grey literature, and Google Scholar (Figure 1).After screening titles and abstracts, 535 duplicates were removed.Following inclusion and exclusion criteria, 230 articles were excluded, with an additional 14 articles after a full-text review, resulting in 23 unique articles for synthesis.Inductive reasoning and thematic analysis categorized systematic reviews into topics, yielding four topics.
As the results in Figure 2 indicate, the United Kingdom, Switzerland, and Australia were the most cited countries for DHD.
The University of Toronto was the leading affiliation, and the Cochrane Database of Systematic Reviews was the leading source for DHD research.

| SYNTHESIS OF THE RESULTS
This section presents an analysis of 23 systematic reviews that identify four main topics that have dominated these articles over the past two decades.These topics are as follows (a complete summary is available in Table C1):   Transfer delays between healthcare providers fueled mistrust.
Notably, caregiver definitions varied between studies: Everall et al. 23 defined them as unpaid family or friends aiding patients, while Rojas-García et al. 24 referred to healthcare and social care practitioners.Standardizing caregiver definitions is crucial for consistent research.Existing literature lacks comprehensive investigation into caregiver experiences, necessitating a unified approach for accuracy.

| Topic 3: Organizational and individual factors that impact DHD
The review articles on DHD in this topic studied its impact considering both organizational and individual factors (Table 4).
Individual factors encompass professional and medical staff roles and, F I G U R E 3 Evolution of the themes over time.
F I G U R E 4 Words co-occurrence in literature abstracts.
to some extent, patient characteristics.Lin et al. 9

| Synthesis of systematic review articles findings
While we encountered various studies conducting systematic examinations, a unanimous definition and measurement standard for DHD was absent.Therefore, we propose a definition of the DHD phenomenon that takes into account key attributes from all review articles we studied as follows: DHD is a situation where a patient has recovered from their acute medical condition and is considered stable, no longer requiring the specialized resources and services provided in the hospital setting.However, due to nonmedical reasons, the patient is not able to transition to the next level of care and leave the hospital.The key attributes of this definition can be found in Table B1, item [1].Additionally, several studies pointed to the importance of understanding patient characteristics, which is crucial for comprehending the root causes of this phenomenon. 3,5,6,8,10,18The following discussion is the answer to our research questions.
R.Q1 What causes and factors contribute to ALC and DHD problems?
The DHD phenomenon and its contributing factors are complex and multifaceted, posing significant challenges to healthcare systems This review aims to address the DHD issue by exploring the inconsistencies in its interpretation, miscommunication and miscoordination, and the role of hospital management practices.The goal was to bridge the gap between research findings and practical applications and to highlight the need for a holistic and patient-centric approach to mitigate DHD and improve healthcare outcomes.

| Technical/administrative and standardized support
Although Micallef et al. have comprehensively defined the DHD term, 5 several articles across all identified topics in this scoping review agreed that the lack of proper standardization makes it more challenging to outline the root causes and that even the term 'medically fit' is vague and can vary from one professional opinion to another. 3,8,13,18Moreover, researchers have noted a concerning trend where studies fail to distinguish between DHD and inappropriate hospital use (patients who have been inappropriately admitted are being combined with those who have been appropriately admitted but are staying longer than necessary due to DHD), leading to conflated data.To ensure reliable outcomes and eliminate inconsistencies, healthcare professionals should embrace standardized definitions and protocols in their studies. 3,8,13On the other hand, numerous articles highlighted inadequate communication and coordination among hospital staff, patients, and healthcare and community institutions.][18]21 This gap in research highlights the need for a discussion that is notably absent in the existing literature: understanding patients' viewpoints and, equally crucial, the caregivers' perspective.This aspect is central to addressing the communication challenges between healthcare professionals and patients. 6,13,23,24,31Additionally, the timing of discharges plays a significant role in DHD issues and subsequent readmissions.For instance, Lin et al. 9 noted that night discharges led to increased mortality rates and premature discharges, emphasizing the impact of decisions made during night shifts on the prevalence of DHD.

| Healthcare management and leadership
]20,23,24  One study questioned the idea of solving DHD by building more transitional care facilities.Instead, it emphasized tackling root causes within hospital management. 21This viewpoint was confirmed by Cadel et al., 6 who argued that adding more transitional care while relieving pressure on ICU units would merely shift the problem from one sector to another.

| Other interventions
17][18]24  | 13 of 32 such collaborative efforts, integrating services like communitybased care programs, discharge planning, and patient information exchange, have experienced decreased readmissions and shorter hospital stays. 15Achieving effective information-sharing between hospitals, community services, patients, and caregivers can be facilitated through several key strategies we discuss in Table B1, item [2].

| Additional insight
Several articles highlighted the oversight of studying the impact of premature discharge, an aspect valuable for insights. 9,15,24Premature discharge, pressured by bed occupancy concerns, can lead to adverse outcomes, increasing readmissions and hospital stays.On the other hand, reviews indicate that when nurses manage the discharge or care transition, patients' process improves compared to physician-led approaches. 9,16

| PROPOSED FRAMEWORK FOR PROCESS IMPROVEMENT
Most articles state their recommendations in terms of focusing on improving the DHD problem.However, they should also explain how to implement their recommendations or suggested solutions in actionable steps.For over two decades, this problem has persisted without implementing long-term solutions.This calls for research investigation and sustainable solutions that can be measured. 6,25,335][36][37] Therefore, our review aimed to guide healthcare policymakers, practitioners, and researchers in tackling the DHD problem.
9][40] CPI, also known as the Kaizen model, has been used in healthcare as a systematic and ongoing approach to enhancing healthcare management's quality of care, safety, and efficiency.It involves identifying, analyzing, and improving processes to optimize patient outcomes. 33,41CPI is not a quick fix but a never-ending journey that requires a commitment to ongoing investment and persistence. 33,38While CPI has been used extensively in the industrial and manufacturing sectors, its effectiveness in healthcare is uncertain due to the healthcare systems' more complex and diverse nature. 34,42However, CPI has shown promise in improving outcomes and reducing costs in various healthcare settings. 35,36,40,42Figure 5 represents our scoping review framework, highlighting our contribution to Linderman's framework. 38Rooted in Linderman's process management improvement model, our framework incorporates adjustments from our review's discussions and recommendations.We introduce the CPI stage, a crucial addition for healthcare institutions seeking to establish a cohesive process improvement framework.
Subsequent sections provide comprehensive insights into each component of our proposed framework.

| Healthcare management and leadership
As explained in the discussion section, healthcare management is one of the main barriers to improving the status of DHD problems in hospitals worldwide.Making improvements to organizational systems requires commitment from senior management.Their involvement is essential to starting the process. 38This must consider both the locational context of the changes and a structure designed for the level of social and technical support that can be implemented. 14,38

| Technical/administrative support
To guarantee systematic improvement, resources regarding information technology usage and healthcare personnel must be well structured and defined.Information technology can be used in several ways, including assessing the patient's physical and socioeconomic conditions.These factors have been shown to affect the expected length of hospital stay and the likelihood of discharge delays. 10In addition, hospitals should have a standard form of discharge that can be used when the patient is admitted and/or discharged to/from the hospital. 8,10,13It is imperative to train nurses It is important to share senior management's goals with the hospital team.This helps motivate them and achieve better performance outcomes.As discussed in the literature, it is also important to train and encourage the social and transitional team to avoid miscommunication 9,18,38 (Figure 6).

| Continuous process improvement
The framework's foundation, built upon Linderman's work, centres on process improvement techniques characterized by its four stages.These stages encompass planning, implementation, data analysis, and adaptation, fostering ongoing enhancement and alignment with evolving healthcare needs and insights.This approach draws inspiration from established methodologies such as the Plan-Do-Study-Act (PDSA) cycle and promotes systemic, iterative healthcare delivery and outcomes improvements (see Figure 7) 34,35,40,43 (detailed explanation can be found in Table B1, item [3]): T A B L E A1 Analysis of causes, barriers, and interventions for delayed hospital discharges.
[1] The main causes and barriers contributing to delayed hospital discharges, as outlined in this review, are multifaceted and include: 1. Lack of rehabilitation services: Patients often face delays due to the unavailability of appropriate rehabilitation services that are necessary for their continued recovery after hospital discharge.2. Hospital-based delays: Inefficiencies within the hospital system, such as bed shortages or administrative hold-ups, contribute to delayed discharges.3. Awaiting transfer: Patients sometimes have to wait for transfer to other hospitals or care facilities, which can cause significant delays.4. Faulty organizational management: Inadequate discharge planning and transfer of care problems, often due to poor organizational management, lead to extended hospital stays. 5. Age-related factors: Older, frail, and dependent individuals are particularly vulnerable to delayed discharges due to their complex health needs.6. Inadequate access to care: Barriers such as inadequate access to residential care, domiciliary support, and limited hospital capacity prevent timely discharge.7. Poor communication: Communication deficits between hospitals, community health and social care providers, and within hospital departments hinder the discharge process.8. Funding difficulties: Financial constraints and funding issues can delay the provision of necessary post-discharge services.9. Patient and carer-related factors: The specific needs of older people with mental health problems and those from minority ethnic communities are not always adequately addressed, leading to delays.10.Delayed assessment and coordination: Delays in patient assessment and lack of coordination between healthcare providers contribute to extended hospital stays.11.Cognitive impairment: Patients with cognitive impairments often experience longer hospital stays due to the need for specialized care and suitable discharge destinations.12. Socioeconomic factors: Patients' socioeconomic status can impact the availability and coordination of post-discharge care, leading to delays.13.Policy struggles: Common policy issues across different countries, such as the lack of jurisdiction-wide approaches, exacerbate the problem of delayed discharges.
[2] The causes or barriers to achieving timely discharge that were repeated in more than one study across topics include: 1. Lack of rehabilitation services: Multiple studies highlighted the absence of adequate rehabilitation services as a barrier to timely discharge.T A B L E B1 Proposed DHD definition, framework, and CPI detailed steps.
[1] Key Attributes of the proposed DHD definition in Section 6.1.Synthesis of Systematic Review Articles Findings 1. Medical readiness: The patient has resolved the acute medical condition requiring hospitalization and is clinically stable (medically fit), with no need for the specialized resources or services of the acute care setting.2. Nonmedical barriers: The delay is attributed to factors beyond the patient's medical condition, such as incomplete assessments, awaiting placement in a more suitable care setting (e.g., rehabilitation, long-term care facility, or home care), or coordination challenges among healthcare providers and services.3. Systemic implications: The delay impacts hospital throughput, leading to inefficient use of healthcare resources, increased risk of iatrogenic harm to the patient, and potential exacerbation of health conditions due to extended hospital stays.4. Patient-centric perspective: Recognizing the patient's experience and the psychosocial impact of delayed discharge, including the risk of functional decline, social isolation, and psychological distress.5. Healthcare coordination: Emphasizes the need for effective communication and collaboration within hospital systems and between acute care and community or social care services to facilitate timely and safe patient transitions.6. Resource utilization: Addresses the broader implications for healthcare systems, such as increased costs, bed shortages, and the cancellation of elective procedures due to prolonged occupancy of acute care beds by patients ready for discharge.
[2] Key strategies for achieving effective information sharing between hospitals, community services, patients, and caregivers: 1. Cross-sectoral access to information: We underscore the importance of electronic access to information across organizational and health sector boundaries.This can be facilitated by implementing integrated health information systems allowing real-time patient data sharing.Such systems ensure that community care providers can access up-to-date medical records, discharge plans, and follow-up care requirements.2. Facilitating partnerships: We recommend establishing networks of care with shared accountability and communication efforts.This involves collaboration between different healthcare providers and organizations to ensure patient transition.Regular meetings and collaborative platforms can help maintain open lines of communication between hospitals, primary care, social services, and other community care organizations.3. Tools and guidelines: The development and implementation of standardized communication tools and guidelines are essential for streamlining the discharge process.These tools may include discharge summaries, checklists, and protocols that ensure all necessary information is communicated clearly and promptly to community service providers.4. Transdisciplinary approach: The inclusion of interdisciplinary communication meetings to discuss bed availability, discharge planning, and coordination of care. 5. Discharge coordinator or liaison nurse: The involvement of a dedicated professional, such as a discharge coordinator or liaison nurse, can facilitate the assessment of patients for transfer, coordinate transfers, and liaise with community care staff during discharge.This role can bridge the gap between hospital and community services, ensuring that information is effectively communicated.6. Patient and caregiver engagement: We emphasize the need for improved communication and enhanced patient engagement.This can be achieved by involving patients and caregivers in the discharge planning process, ensuring they understand the care plan and are prepared for the transition from hospital to home or another care setting.

APPENDIX B: PROPOSED FRAMEWORK, DHD DEFINITION AND CPI
Table B1 1. Planning: In this initial stage, healthcare professionals should define the objectives informed by direct input from patients and caregivers.Engage them in focus groups or surveys to understand their needs and expectations.Develop a discharge planning process that includes patient education, anticipates post-discharge needs, and sets clear expectations for follow-up care.Standardized discharge forms should be designed to be patient-friendly and include sections for patient feedback and concerns.2. Implementation: As changes are executed, ensure that the patients' and caregivers' roles are clearly defined and supported.Provide training for nurses responsible for discharge planning and training for patients and caregivers on post-discharge care, medication management, and warning signs of potential complications.Implement a system for regular check-ins with patients and caregivers to address any issues during the discharge process.Document all patient and caregiver interactions to identify areas for improvement.3. Data analysis: Analyse data from healthcare team observations and patient and caregiver feedback.Assess patient satisfaction with the discharge process and the clarity of the information provided.Evaluate the effectiveness of the support and education provided to caregivers.Use this data to understand where the discharge process meets patient needs and where it falls short.4. Adaptation: Based on the analysis, adapt the discharge process to better meet the needs of patients and caregivers and align with the healthcare professional feedback and observations.This could involve revising educational materials, improving communication strategies, or altering follow-up procedures.Ensure that any changes are communicated back to patients and caregivers and that their ongoing feedback is solicited to continue the improvement cycle.
T A B L E C1 Characteristics of all the articles.2. The medical characteristics of the patients, particularly the elderly, frail, and dependent individuals, were identified as significant contributors to delayed discharge.
3. Family refusal of home-based care and lack of alternative care centres accounted for a significant percentage of delayed discharge cases.
4. The complexity of patients' processes was linked to delayed discharges.
5. Certain medical conditions, such as acute cerebrovascular disease, were associated with a higher prevalence of delayed discharges.To assess the effectiveness of planning the discharge of individual patients moving from the hospital

Figure 3
Figure 3 illustrates the thematic evolution from 132 Scopus articles on DHD, showing how frequent words in abstracts have shifted over time, reflecting evolving research contexts.Connections between themes demonstrate keyword development, convergence, or divergence, with recent trends highlighting social care, recovery, and patient outcomes.The persistent presence of 'delayed discharge' underscores ongoing challenges.Figure 4 visualizes word co-occurrences, revealing DHD's impacts on the female population over two decades.

14 (F
Tipton et al.'s report echoed concerns regarding medically complex patients facing heightened risks of discharge delays, elucidating the plethora of interventions designed to curtail hospital length of stay, albeit with inconsistent evidence, necessitating further scrutiny.30Åhlin et al.'s identification of barriers to patient throughput within hospital settings elucidated pervasive challenges like long lead times and inefficient capacity coordination, alongside root causes such as staffing inadequacies and operational deficiencies, underpinning the imperative for systematic reforms. 12Similarly, Cadel et al.'s review elucidated an array of interventions encompassing practice changes, information-sharing initiatives, and infrastructure enhancements, all geared towards expediting discharge processes and ameliorating delay-related burdens. 6However, they expressed dissatisfaction with the lack of detailed insights into patient, caregiver, and provider experiences, urging more comprehensive investigations.Micallef et al.'s finding of organizational impediments underscored the pivotal role of strategic interventions such as developing discharge facilitation tools and 'discharge before noon' policies in streamlining discharge workflows. 5Meanwhile, Sluisveld et al.'s scrutiny of patient handover quality highlighted deficiencies in clinical practices and communication protocols, advocating for adopting liaison nurse roles and standardized handover protocols to enhance continuity of care and mitigate discharge-related adversities. 16Philp et al.'s comprehensive analysis investigated the escalating demand for acute hospital beds, accentuating the necessity of interventions like care coordination and community-based rehabilitation services to alleviate strain on hospital resources and ensure seamless transitions post-discharge for frail older populations. 15Landeiro et al.'s examination of costs associated with DHD provided valuable economic perspectives, emphasizing the imperative for methodological standardization to facilitate comparative analyses and informed resource allocations. 3Rameli et al.'s emphasis on individualized care pathways underscored the significance of holistic approaches in optimizing discharge F I G U R E 1 PRISMA flowchart of the selection process for literature review.outcomesfor older adults, stressing the pivotal role of multidisciplinary discharge planning teams.17Similarly, Gonçalves-Bradley et al.'s emphasis on personalized discharge plans highlighted the potential for tailored interventions in reducing hospital length of stay, albeit with acknowledgement of the need for robust evidence to drive effective implementation strategies. 31Gonçalves-Bradley et al.'s updated review reiterated persistent causes of DHD, advocating for structured discharge planning and streamlined post-discharge services as pivotal interventions to mitigate delay-related adversities. 19Lastly, Bhatia et al.'s critique of existing approaches illuminated systemic challenges in tackling DHD, warranting more holistic, jurisdiction-wide strategies to effectively address the DHD problem's multifaceted nature effectively.I G U R E 2 (A) Most cited countries, (B) most frequent (relevant) affiliations, and (C) most relevant publications source.

5. 2 |
Topic 2: Patient and caregiver experience of DHD Two systematic reviews shed light on the experiences of patients and caregivers affected by DHD, as detailed in Table3.Everall et al.23 identified strategies to alleviate DHD, including providing timely information to patients and families, enhancing patient mobility, addressing long-term care wait lists, and supporting couples.They recommended staff training on transitional and patient-centred care, patient feedback avenues, and handover support.Confirming DHD as a system-level issue, Rojas-García et al.24 emphasized DHD's adverse impacts on patient well-being and hospital experiences, citing anxiety, boredom, and loss of independence.Caregivers, comprising hospital staff, faced stress and pressure to expedite discharge.

6 |
DISCUSSION This scoping review of systematic review articles delves into the multifaceted causes of DHD, including service shortages, hospitalbased delays, inadequate access to care, and patient-specific factors like age and CI.Effective interventions, such as expanding community care services and implementing transition navigator roles, have been identified, though their efficacy is often questioned due to study limitations.The review emphasizes DHD's emotional and physical toll on patients and caregivers, stressing the need for timely information and policy revisions.Organizational and individual factors significantly influence DHD, with early discharge planning and care coordination showing promise.Despite efforts, research gaps persist, particularly regarding patient and caregiver experiences and intervention sustainability.Our review underscores the need for standardized, multidimensional approaches to address DHD effectively.Additionally, this review integrates findings from 23 articles spanning more than two decades, offering insights into prioritizing research areas and providing a framework for administrators and policymakers to enhance current practices sustainably.
worldwide.Although defined by Micallef et al.,5 the term DHD lacks consistency across various studies, making it difficult to pinpoint the root causes and standardize interventions.The vagueness of terms such as 'medically fit' further complicates the understanding of DHD, as professional opinions on the matter can vary widely.This scoping review sought to elucidate the technical, administrative, and communicative issues that contribute to DHD and the role of healthcare management and leadership in addressing these issues.

F I G U R E 5 16 7. 3 |
Healthcare process improvement framework to reduce Delayed Hospital Discharge.on handling planned hospital discharges to ensure a seamless patient flow starting from the admission phase. 9,Social/transitional/continuous care support Social, transitional, and continuity of care are essential in improving DHD.
Characteristics of the articles of Topic 2. Characteristics of the articles of Topic 3. Characteristics of the Articles of Topic 4.
20x et al.209 NA Failure to plan discharge planning upon patient admission to the hospital.1.Patients who did not receive early discharge planning experienced higher readmission rates and longer lengths of readmission hospital stay.2.Compared to usual care, those who received early discharge planning had higher overall quality of life scores.3.Implementing early discharge planning focused on functional needs assessment anticipates reductions in older adults' hospital readmissions by 22%. 4. The goal of early discharge planning is to facilitate the transition of care back to the community.Lin et al. 9 21 Up to 2009 1. Lack of agreement in clinical decision-making.2.The ward staff's lack of knowledge and skills to look after the higher acuity patient.3.Teams make fewer mistakes when each member understands their roles and responsibilities.4.A multidisciplinary team involved in daily goal setting reduced adverse events.5.Improved communication and collaboration among ICU doctors and nurses through team training decreased patient ICU mortality 1.The triage discharge model must be cautiously used to avoid premature discharge.2.The lack of agreement in discharge decision-making indicates a problem in staff training.Abbreviation: DHD, Delayed Hospital Discharge.T A B L E 5 3. Account for social vulnerabilities, including discharge planning.4. Better acute care practices can occur upstream instead of focusing on repairing losses that occurred in hospitals.
delineated patient factors within their framework but could not investigate them due to their complexity.Organizational factors include resource availability, discharge policies, and interventions like ICU liaison nurses, which enhance ICU performance, reduce hospital stays, and lower patient mortality.Individual factors, like clinical decision-making discrepancies and nurses' proactive bed management, were emphasized.
14 often prolonged hospitalization, with prevalence varying from 4.6% to 63% among DHD patients.Future research should address CI's effects on healthcare systems and caregiver costs.Modas et al.10evaluated tools for predicting prolonged hospitalization and DHD risk, focusing on cognitive function, age, daily living activities, mobility, and social support.Preventive methodologies and early discharge planning, coupled with tools like the multidisciplinary record, were effective in mitigating DHD.However, limitations included subjective assessments of social days and the need for more variables and diverse clinical testing.These studies highlight the complex nature of DHD and emphasize the need for comprehensive approaches that integrate individual and organizational interventions while addressing the challenges of defining and measuring its impact.5.4 | Topic 4:Transitional and social care and the role of funding25suggested that integrated funding may enhance care access but does not consistently yield significant health benefits or cost reductions.While earlier intervention and shorter stays were associated with mitigating DHD, challenges in implementing financial integration and linking information systems were outlined.Bhatia et al.14highlighted the insufficiency of financial incentives in reducing DHD rates, Policy reform, enhanced communication, and targeted support for vulnerable groups are recommended.Table A1 summarizes the primary causes, recurring themes, interventions, and trends in DHD research.

Table A1 7
. Resource availability: A recurring theme was a shortage of ICU beds and other hospital resources, leading to delayed discharges.8. Inadequate discharge planning: Faulty organizational management and inadequate discharge planning were identified as root causes of DHD. 9. Age-related factors: The challenges associated with the discharge of older, frail, and dependent individuals were frequently mentioned.10.Cognitive impairment (CI): The association between CI and increased length of stay or DHD was highlighted in multiple studies.Preventive health checks and geriatric assessment units: These interventions focus on the specific needs of older patients and have been effective in reducing hospital stays. 5. Care home liaison and community-based rehabilitation services: These services help bridge the gap between hospital care and community or residential care, aiding in the transition and reducing readmissions.6. Nurse-led discharge planning: Involving nurses in the discharge planning process has helped mitigate delayed discharges by ensuring that patient care continues seamlessly after leaving the hospital.7. Development of discharge facilitation Tools: Tools such as 'discharge before noon' policies and tracking mechanisms help identify and address factors hindering early discharge.8. Involvement of general practitioners and Social Care Staff: Engaging these professionals in the discharge process ensures better coordination and continuity of care.
A B L E C2 Full description of the aim of the study, inclusion, and exclusion criteria of each selected article. T